Contributors LB, AN and LR designed the study. LB prepared the data, completed the first analysis and wrote the first draft. AN and LR
helped further refine the analysis and contributed to further drafts. LR is the guarantor. All authors had full access to
all the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Accepted 12 February 2012

Published Online First 20 March 2012

Abstract

Background In the UK, epilepsy is the neurological condition with the highest rate of accident and emergency department re-attendance,
with most arriving by ambulance. Ambulance clinicians triage patients and assess their need for attendance. This study examined
the decision-making process of ambulance clinicians in these situations.

Methods In-depth interviews with 15 ambulance clinicians working in South London.

Results Interviewees identified that epileptic seizures that self-resolve present a triage challenge. They reported insufficient
training and guidance available for these situations and substantial reliance on experience to direct their practice. Fears
of litigation in the event of complications, pressures of public expectation and limited on-scene access to relevant patient
information or appropriate alternative care pathways were reported to be significant factors influencing decisions for care
for epilepsy seizures.

Discussion Ambulance clinicians reported negotiating a balance between patient safety and patient choice, when deciding whether to transport
a patient with epilepsy to hospital or not. Clinician fears and the pressures and limitations of practice may result in hospital
conveyance being used as a safety precaution in some instances.

Conclusions Decisions regarding conveyance of patients with epilepsy in this study were substantially guided by ambulance clinician experience
rather than by robust training and guidelines. This study supports the need for improved guidance that addresses this common
area of practice and the development of alternative care pathways that may be used by ambulance clinicians for patients with
epilepsy.

Footnotes

Funding The study was supported by a National Institute for Health Research Service Delivery and Organisation (NIHR SDO) grant (08/1815/234).
The funders had no role in the design or conduct of this review, or in the preparation, review, or approval of the manuscript.
All authors carried out this research independently of funding bodies. This study was completed by LB in part requirement
for an MSc in Clinical Neuroscience at King's College London.

Competing interests The authors declare: (1) no financial support for the submitted work from National Institute for Health Research Service
Delivery and Organisation Programme; (2) no financial relationships with commercial entities that might have an interest in
the submitted work; (3) no spouses, partners or children with relationships with commercial entities that might have an interest
in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.

Ethics approval The National Research Ethics Service considered this study did not require ethical approval. Approval granted by the London
Ambulance Service Clinical Audit and Research Department reference number LAS/SE/2010/05. Permission was obtained from the
London Ambulance Service Clinical Audit and Research group for research to be conducted and submitted for publication (ref
number LAS/SE/2010/05). Informed consent was obtained from individual participants.